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To the Editor:-Lubarsky [1,2] dismisses the concerns of Riley [3] and Bailey and Egan [4] who question the magnitude of savings that would be attained using Lubarsky et al.'s pharmaceutical practice guidelines. [5] When Riley noted that a 3-min increase in “emergence time” would increase costs at his institution, Lubarsky replied that this cost would be incurred only at Riley's institution. However, the same increased costs would be incurred at our hospital (and possibly others), in which nurses chronically work overtime. In addition, Lubarsky dismisses a 3-min savings as not detectable by an accounting system. We doubt this. As an analogy, if General Motors could shave 3 min off the production time for each vehicle, it would certainly do so!

Similarly, Lubarsky claims that Riley is “mistaken in his analysis of the one case of prolonged mechanical ventilation resulting from pancuronium administration” because the difference in incidence of adverse events “was not any different before versus after the implementation of practice guidelines.” Although he is correct, he should acknowledge that his study is underpowered for detecting an increased incidence of severe (and potentially extremely costly) adverse events.

A more important issue has been completely ignored by Lubarsky et al. in their economic analysis. If anesthesiologists are under pressure to reduce costs, so are surgeons (and other operating room personnel). In our institution (which is presumably similar to Lubarsky's), surgical attendings are now present during a larger percentage of the procedure than in past years, and skin closure is no longer delegated to undersupervised medical students. In support of this, Macario et al. [6] recently reported that operating room costs for patients undergoing prostatectomy decreased 7% during sequential periods during which no special cost-saving techniques were implemented. If similar changes occurred at Duke University, case duration probably should have decreased during the course of Lubarsky's study. In contrast, their Figure 1shows that case duration increased from 2.7 h to 2.9 h during the course of their study. The cost of this 12-min increase in case duration probably overwhelms the savings on anesthetic drugs.

Unfortunately the study design used by Lubarsky et al. (data obtained during sequential periods) does not permit them to truly claim cost savings. Until a randomized, prospective trial examining all perioperative costs is performed, we remain unconvinced that the answer is known. Hopefully, recent research and correspondence in this journal has piqued the interest of investigators.

Dennis M. Fisher, M.D.

Professor of Anesthesia and Pediatrics

Scott D. Kelley, M.D.

Associate Professor of Anesthesia; University of California; San Francisco, California 94143–0648